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Abstract：
OBJECTIVE: Visit-to-visit systolic blood pressure variability (BPV) is an important predictor of cardiovascular (CV) outcomes. The long-term effect of a period of blood pressure (BP) control, but with differential BPV, is uncertain. Morbidity and mortality follow-up of UK participants in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure-Lowering Arm has been extended for up to 21 years to determine the CV impact of mean systolic blood pressure (SBP) control and BPV during the trial, and amongst those allocated to amlodipine- and atenolol-based treatment.
METHODS: Eight thousand five hundred and eighty hypertensive participants (4305 assigned to amlodipine ± perindopril-based and 4275 to atenolol ± diuretic-based treatment during the in-trial period (median 5.5 years) were followed for up to 21 years (median 17.4 years), using linked hospital and mortality records. A subgroup of participants (n = 2156) was followed up 6 years after the trial closure with a self-administered questionnaire and a clinic visit. In-trial mean SBP and standard deviation of visit-to-visit SBP as a measure of BPV, were measured using >100 000 BP measurements. Cox proportional hazard models were used to estimate the risk [hazard ratios (HRs)], associated with (i) mean with SBP and BPV during the in-trial period, for the CV endpoints occurring after the end of the trial and (ii) randomly assigned treatment to events following randomization, for the first occurrence of pre-specified CV outcomes.
RESULTS: Using BP data from the in-trial period, in the post-trial period, although mean SBP was a predictor of CV outcomes {HR per 10 mmHg, 1.14 [95% confidence interval (CI) 1.10-1.17], P < .001}, systolic BPV independent of mean SBP was a strong predictor of CV events [HR per 5 mmHg 1.22 (95% CI 1.18-1.26), P < .001] and predicted events even in participants with well-controlled BP. During 21-year follow-up, those on amlodipine-based compared with atenolol-based in-trial treatment had significantly reduced risk of stroke [HR 0.82 (95% CI 0.72-0.93), P = .003], total CV events [HR 0.93 (95% CI 0.88-0.98), P = .008], total coronary events [HR 0.92 (95% CI 0.86-0.99), P = .024], and atrial fibrillation [HR 0.91 (95% CI 0.83-0.99), P = .030], with weaker evidence of a difference in CV mortality [HR 0.91 (95% CI 0.82-1.01), P = .073]. There was no significant difference in the incidence of non-fatal myocardial infarction and fatal coronary heart disease, heart failure, and all-cause mortality.
CONCLUSIONS: Systolic BPV is a strong predictor of CV outcome, even in those with controlled SBP. The long-term benefits of amlodipine-based treatment compared with atenolol-based treatment in reducing CV events appear to be primarily mediated by an effect on systolic BPV during the trial period.
METHODS: Eight thousand five hundred and eighty hypertensive participants (4305 assigned to amlodipine ± perindopril-based and 4275 to atenolol ± diuretic-based treatment during the in-trial period (median 5.5 years) were followed for up to 21 years (median 17.4 years), using linked hospital and mortality records. A subgroup of participants (n = 2156) was followed up 6 years after the trial closure with a self-administered questionnaire and a clinic visit. In-trial mean SBP and standard deviation of visit-to-visit SBP as a measure of BPV, were measured using >100 000 BP measurements. Cox proportional hazard models were used to estimate the risk [hazard ratios (HRs)], associated with (i) mean with SBP and BPV during the in-trial period, for the CV endpoints occurring after the end of the trial and (ii) randomly assigned treatment to events following randomization, for the first occurrence of pre-specified CV outcomes.
RESULTS: Using BP data from the in-trial period, in the post-trial period, although mean SBP was a predictor of CV outcomes {HR per 10 mmHg, 1.14 [95% confidence interval (CI) 1.10-1.17], P < .001}, systolic BPV independent of mean SBP was a strong predictor of CV events [HR per 5 mmHg 1.22 (95% CI 1.18-1.26), P < .001] and predicted events even in participants with well-controlled BP. During 21-year follow-up, those on amlodipine-based compared with atenolol-based in-trial treatment had significantly reduced risk of stroke [HR 0.82 (95% CI 0.72-0.93), P = .003], total CV events [HR 0.93 (95% CI 0.88-0.98), P = .008], total coronary events [HR 0.92 (95% CI 0.86-0.99), P = .024], and atrial fibrillation [HR 0.91 (95% CI 0.83-0.99), P = .030], with weaker evidence of a difference in CV mortality [HR 0.91 (95% CI 0.82-1.01), P = .073]. There was no significant difference in the incidence of non-fatal myocardial infarction and fatal coronary heart disease, heart failure, and all-cause mortality.
CONCLUSIONS: Systolic BPV is a strong predictor of CV outcome, even in those with controlled SBP. The long-term benefits of amlodipine-based treatment compared with atenolol-based treatment in reducing CV events appear to be primarily mediated by an effect on systolic BPV during the trial period.
摘要：
目的：访视收缩压变异性（BPV）是心血管（CV）结局的重要预测指标。一段时间的血压（BP）控制的长期效果，但是有了差分BPV，不确定。英国参与者在英裔斯堪的纳维亚心脏结果试验-血压降低臂的发病率和死亡率随访已延长了长达21年，以确定平均收缩压（SBP）控制和BPV的CV影响试验期间，以及分配给氨氯地平和阿替洛尔治疗的患者。
方法：在试验期间（中位5.5年），随访了8000名高血压参与者（4305名患者接受氨氯地平±培多普利治疗，4275名患者接受阿替洛尔±利尿剂治疗，随访时间长达21年（中位17.4年），使用关联的医院和死亡率记录。试验结束后6年，对一组参与者（n=2156）进行了自我问卷调查和临床访问。试验中平均SBP和访视SBP的标准偏差作为BPV的量度，使用>100000BP测量进行测量。Cox比例风险模型用于估计风险[风险比(HR)]，与(I)试验期间SBP和BPV的平均值相关，对于在试验结束后发生的CV终点和(ii)随机分配治疗随机分组后的事件，首次出现预先指定的CV结果。
结果：使用试用期的BP数据，在审判后阶段,尽管平均SBP是CV结果的预测因子{HR每10mmHg，1.14[95%置信区间（CI）1.10-1.17]，P<.001},独立于平均SBP的收缩期BPV是CV事件的强预测因子[HR/5mmHg1.22(95%CI1.18-1.26),P<.001]和预测事件，即使在血压控制良好的参与者中也是如此。在21年的随访中，与以阿替洛尔为基础的试验治疗相比，以氨氯地平为基础的患者卒中风险显著降低[HR0.82(95%CI0.72-0.93)，P=.003],总CV事件[HR0.93（95%CI0.88-0.98），P=.008],总冠状动脉事件[HR0.92（95%CI0.86-0.99），P=.024],和心房颤动[HR0.91（95%CI0.83-0.99），P=.030],心血管死亡率差异的证据较弱[HR0.91(95%CI0.82-1.01)，P=.073]。非致死性心肌梗死和致死性冠心病的发生率无显著差异,心力衰竭,和全因死亡率。
结论：收缩期BPV是CV结局的强预测因子，即使是那些控制SBP的人。与基于阿替洛尔的治疗相比，基于氨氯地平的治疗在减少CV事件方面的长期益处似乎主要由试验期间对收缩期BPV的影响介导。
方法：在试验期间（中位5.5年），随访了8000名高血压参与者（4305名患者接受氨氯地平±培多普利治疗，4275名患者接受阿替洛尔±利尿剂治疗，随访时间长达21年（中位17.4年），使用关联的医院和死亡率记录。试验结束后6年，对一组参与者（n=2156）进行了自我问卷调查和临床访问。试验中平均SBP和访视SBP的标准偏差作为BPV的量度，使用>100000BP测量进行测量。Cox比例风险模型用于估计风险[风险比(HR)]，与(I)试验期间SBP和BPV的平均值相关，对于在试验结束后发生的CV终点和(ii)随机分配治疗随机分组后的事件，首次出现预先指定的CV结果。
结果：使用试用期的BP数据，在审判后阶段,尽管平均SBP是CV结果的预测因子{HR每10mmHg，1.14[95%置信区间（CI）1.10-1.17]，P<.001},独立于平均SBP的收缩期BPV是CV事件的强预测因子[HR/5mmHg1.22(95%CI1.18-1.26),P<.001]和预测事件，即使在血压控制良好的参与者中也是如此。在21年的随访中，与以阿替洛尔为基础的试验治疗相比，以氨氯地平为基础的患者卒中风险显著降低[HR0.82(95%CI0.72-0.93)，P=.003],总CV事件[HR0.93（95%CI0.88-0.98），P=.008],总冠状动脉事件[HR0.92（95%CI0.86-0.99），P=.024],和心房颤动[HR0.91（95%CI0.83-0.99），P=.030],心血管死亡率差异的证据较弱[HR0.91(95%CI0.82-1.01)，P=.073]。非致死性心肌梗死和致死性冠心病的发生率无显著差异,心力衰竭,和全因死亡率。
结论：收缩期BPV是CV结局的强预测因子，即使是那些控制SBP的人。与基于阿替洛尔的治疗相比，基于氨氯地平的治疗在减少CV事件方面的长期益处似乎主要由试验期间对收缩期BPV的影响介导。
